Melody Bethards

    In a recent Pocket Nurse® survey, 30 percent of the 555 healthcare educators who responded noted that student engagement and retention were their biggest professional challenges. Disengagement in a simulation or clinical environment can be detrimental to student learning and retention.

    What does disengagement look like in simulated clinical settings?

    Students often show disengagement during prebriefing/preparation activities, scenarios, and debriefing. During prebriefing/preparation activities disengaged students do not actively provide input into briefing activities or preparation discussions. They may appear to be researching information on their computer but are checking email or working on other non-related activities. When directly asked to provide input they will repeat something said by another participant.

    Disengaged students will assume roles such as writing notes on the white board or serving as a “runner” for supplies, medications, etc. during scenarios. They prefer to remain in the background, declining to actively engage with the simulated patient. Students who are disengaged during scenarios often express fear or hesitation through their body language and facial expressions.

    During debriefing, disengaged students are withdrawn and fail to provide input during discussions. They will often seat themselves as far as possible from the facilitator. When directly asked a question, they may repeat what was said by another participant or may just say, “I agree with everyone else.” Here again, body language will show whether or not the students are engaged in debriefing.

    Learning in the simulation setting relies on hands-on experience. Always functioning in the role of observer isn’t enough to establish proficiency. As healthcare education focuses more on scenario-based training, students who fail to go all-in will fall farther behind.

    What causes disengagement in the simulated clinical setting?

    I find students often fail to engage in simulation learning experiences for three primary reasons:

    • Lack of confidence: Students lacking in confidence are often afraid of providing incorrect information or failing in front of their peers. Mistakes won’t harm simulated participants in the simulated setting, but they can seem embarrassing.
    • Lack of knowledge: Students who are disengaged in one aspect of learning are often disengaged in other aspects as well. If a student isn’t studying/participating in classroom or laboratory learning activities, it’s likely they will not be ready to apply theoretical skills during scenarios.
    • Lack of preparedness: This lack of preparedness can be related to not completing pre-simulation assignments or engaging in prebriefing/preparation activities.

    How to address disengagement in simulation learning experiences

    The best way to address disengagement is to ensure that simulation learning experiences are implemented following the INACSL Standards of Best Practice: SimulationSM (2016).

    Simulation facilitators must first and foremost ensure a psychologically safe learning environment. This includes, but is not limited to, ensuring scenarios are designed appropriately for the purpose of simulation in the program; ensuring there are no consequences for making mistakes during scenarios; and focus on learning during debriefing and not who is responsible for errors.

    It is important to ensure all students have the opportunity to develop the skill of recognizing their own limitations and strengths, and when they should step up or step aside. Simulation facilitators need to maintain a delicate balance of encouraging engagement and providing opportunities to hone teamwork and collaboration skills for all students participating in simulation learning activities.

    Here are additional suggestions to help manage disengagement:

    • Consider establishing a process for assigning leadership roles for each component of the simulation learning experience (prebriefing/preparatory activities, scenarios, and debriefing), and rotating these responsibilities among students.
    • Students often have a tendency to “protect” disengaged students, unintentionally impairing their learning. Facilitators need to be aware of how students are participating in their assigned roles and address concerns with students who do not fulfill their role or take over someone else’s assigned role.
    • Don’t confront disengaged students publicly. This will likely aggravate any insecurities and fears. Instead, pull them aside and explain just how crucial engagement is for all learners.
    • If possible, organize groups based on past engagement. For students who tend to hang back or let others assume a more active role this will require that all participants actively engage in the simulation learning experience in order to meet learning objectives.


    The INACSL Standards Committee (2016, December). INACSL Standards of Best Practice: SimulationSM. Clinical Simulation in Nursing, Volume 12, Supplement, S1-S50.

    Melody Bethards, MSN, RN, CNE, CHSE is the Health and Public Services/Nursing Simulation Coordinator for Des Moines Area Community College. She has been working in healthcare simulation for over 10 years. Bethards is currently pursuing a doctorate in education. Her dissertation is on evaluating underperforming nursing students in traditional and simulated clinical settings.